Access The Netherlands

Radical cost-cutting reforms in healthcare, centred on generic prescribing, require a new set of thinking to get a drug into this market

The Netherlands has one of the highest-rated health services in the world. However, as the Dutch government looks to address spiralling healthcare costs through an emphasis on greater efficiency and consistency, there has been a fundamental shift in the way healthcare services are provided and funded across the country.

Certainly, The Netherlands is leading the way in Europe with highly aggressive targets for the adoption of generics. Not only has the government set a target that 80 per cent of drugs prescribed must be generic, but clinicians are not allowed to prescribe by brand name, only product class, to enable a pharmacist to switch to a generic option automatically when a drug comes off patent.

Furthermore, the price of generics has plummeted in recent years, by 80-90 per cent, with some drugs that used to cost €10, now costing no more than 50 cents. The reason behind this lies in a policy preference by the insurance companies, which only reimburse the lowest-priced generic.

This emphasis on cost and efficiency was at the heart of a fundamental shift away from a centralised public system to a highly decentralised private system in 2006, with healthcare insurance companies taking on the role of purchasing care. While it has taken a few years for the new model to settle down, the implications have been significant. The creation of a demand-led market has led to the closure of some hospital departments and specialities, while the insurance companies have also implemented new payment models for patients with chronic diseases such as diabetes.

New structureThe structural changes have also affected the way primary care is delivered, with general practitioners (GPs) encouraged not to operate in isolation but to co-operate within the framework of a care group.

While any organisation can set up a care group – and some have been created by the increasingly influential patient associations – the vast majority are GP-led. Today, around 80 per cent of GPs are associated with one of the 140 care groups which act as an interface between the GPs and health insurance companies.

The care groups have an increasingly broad remit. They include pharmacists and, reinforcing plans to reduce the reliance on expensive secondary care, the Dutch government has encouraged them to forge relationships with specialist consultants too, so that many of these individuals are now regularly offering clinics in the primary care environment.

ContractThe care group makes a contract with the insurance companies and they agree upon a specific price per patient per year. For this fixed amount, the care group, or that is to say, the healthcare providers, such as the GPs, dieticians and practice nurses, provides the necessary healthcare.

At present, the care groups are concerned with looking after chronic patients with diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular problems. These indications will be extended in the future. The idea is that by having the care group arrange the patient's care, with the involvement of the GPs and nurses, greater efficiency can be achieved.

For the pharmaceutical companies, the creation of care groups has led to significant change. There is now little or no direct contact with GPs

In addition, these GPs must demonstrate adherence to treatment protocols to ensure standardised treatment in specific disease areas. While the government has developed a number of such protocols, care groups are not obliged to follow protocols developed by the government and can opt to follow other models approved by the healthcare insurance partner.

As yet, these protocols do not include specific drug therapies; this is likely to come within the next 12 to 18 months, further increasing the influence of the health insurance company. They have, however, significantly increased the role of practice nurses in managing chronic conditions within primary care, a point which has growing resonance for pharmaceutical companies considering the issue of patient adherence/compliance.

For the pharmaceutical companies, the creation of care groups has led to significant change. There is now little or no direct contact with GPs. Recent figures suggest that almost 30 per cent of GPs are visited just one to four times a year and large numbers receive no visits at all.

Relationship buildingGetting the product approved at a good price is becoming more difficult, as market access must also focus on building relationships with the care groups. However, these are completely new organisations. Pharmaceutical companies have no relationships with care group management. The first challenge, therefore, when creating a relevant market access strategy, is to gain insight into these new organisations, to understand which GPs, pharmacists and specialist clinicians are working with which care groups. Next it is to ascertain the relationships in place with health insurance companies and the guidelines adopted for each disease area.

New influencersThe significance of these guidelines cannot be overlooked. Given the emphasis on generics and the automated switch from branded to generic products post-patent, there is huge pressure on pharmaceutical companies to reduce both the time to market and maximise product market value while under patent. The market access strategy must, therefore, reflect the growing influence of an extraordinary number of new influences, including healthcare insurers, pricing and reimbursement agencies, health technology assessment bodies, physician and patient associations.

Understand networksIf a pharmaceutical company fails to address those individuals responsible for determining treatment protocols and guidelines, at both national and care group level, approval and pricing decisions will be irrelevant.

In order to get the product approved, reimbursed, paid for by the insurance companies, purchased by a hospital, included in a formulary and prescribed, pharmaceutical companies must ensure they cultivate in-depth insight into all individuals and networks across the health service, from the head of a government body to a care group manager. They must understand the place of each of these in the health network and how they interact to determine the most effective market access strategy, from the timing of interaction to relevance of messaging.

ConclusionIn 2010, pharmaceutical companies in The Netherlands took some difficult decisions. Headcount was reduced by 50 per cent; sales representatives were been replaced by key accounts managers (KAMs) and companies are recognising the need for proper reimbursement and the impact of government-created protocols for patient care. KAMs now have a diverse range of influencers to address; each with different motivations, objectives and financial considerations. At the same time, KAMs cannot afford to ignore the growing need for more direct contact with healthcare insurers, given these organisations' expected influence over drug decision-making in the next 12 to 18 months and the implications for drug use within treatment protocols.

Key challengeThis is the key challenge facing pharmaceutical companies in The Netherlands: to develop a market access strategy that not only gets the product approved at the right price, but also ensures it retains traction throughout its patented life within a market increasingly dominated by treatment guidelines.